clinical and radiological evaluation are fundamental in the decision-making process in tongue cancer.

Pathological aspects of tumor pathways of progression and different structures of the oral cavity involved are in some cases can be trickier to assess.

Radiological workup is made mainly with MRI in order to have a clear vision of all the muscolar e soft tissue components of the oral cavity.

Only after a strict evaluation of these aspects radical excision of the tumor can be programmed.

Recent classification of glossectomies gave a better understanding of how different cases can be correctly handled surgically.

In oral cavity cancer more than in other head and neck districts it is very important to obtain radicality by clear margins in order to obtain the best oncological results. Nevertheless, residual functions like swallowing and speech need to be also considered.

The management of head and neck cancer (HNC) requires a multidisciplinary, guideline-driven approach to optimize outcomes and minimize morbidity. Unfortunately, a subset of patients is still being treated outside of established protocols, often leading to suboptimal oncologic control, functional impairments, and complex salvage scenarios. This retrospective clinical reflection highlights several emblematic cases of inadequately treated HNC patients referred to our center for secondary management.

Our analysis focuses on patients who initially underwent incomplete, inappropriate, or delayed treatment in non-specialized centers. Common issues included: lack of proper staging before treatment, non-standard surgical approaches without clear margins, omission of adjuvant therapy when indicated, or poorly planned radiotherapy. These deviations frequently resulted in early recurrence, persistent disease, or major complications involving speech, swallowing, and airway integrity.

Through selected clinical cases, we explore the practical, ethical, and therapeutic challenges involved in managing these patients. Salvage treatments – whether surgical, radiotherapeutic, or systemic – are often technically more demanding and oncologically less effective than primary treatments delivered within guidelines. In addition, prior suboptimal treatment often compromises anatomical structures and patient performance status, making optimal recovery difficult.

This clinical case-based review also raises broader questions regarding referral practices, the role of second opinions, and the need for early multidisciplinary evaluation. It aims to prompt reflection among clinicians on the consequences of deviating from evidence-based care in HNC and to encourage systemic improvements in patient pathways. We also emphasize the psychological burden these patients carry and the difficulty in restoring their trust after prior mismanagement.

Ultimately, while reconstructive and salvage interventions are necessary and sometimes life-saving, they are rarely equivalent to getting it right the first time. Prevention, through timely referral and coordinated care in high-volume, specialized centers, remains the most effective and ethical solution.

The management of surgical margins in oral cavity squamous cell carcinoma is a subject of ongoing debate in current literature. While most clinical guidelines define resection margins based on geometric parameters—typically >5 mm in planar measurement or >7 mm³ in three-dimensional assessment—this approach may not account for the complex anatomical and biological variability of the oral cavity. Modern approaches advocate for a more nuanced view that considers the variability in tumor subsites and structural anatomy, as well as key factors such as the tumor infiltration front, the mode of tumor progression (mucosal versus stromal), and the involvement of critical anatomical spaces like the sublingual areas, the T-N tract, and the infratemporal fossa.

There is also ongoing discussion regarding the most effective methods for evaluating surgical margins, including imaging techniques, bioendoscopy, and intraoperative frozen section analysis, with no standardized decision-making algorithm currently established.